Doorstep Delivery Increases Adoption of Contraceptives in Rural Areas of Pakistan
In rural Pakistan, married women living in a household served by a community-based health worker are more likely than other married women to currently use a modern reversible contraceptive.1 Data from a national evaluation of the community-based Lady Health Worker Program indicate that women in rural areas served by the program had 50% higher odds of using such a method, compared with women in control areas. Women in program areas were also more likely to have ever used such a method.
The program, formally known as the National Program of Family Planning and Primary Health Care, uses trained employees called lady health workers to provide doorstep delivery of services, including basic preventive care and contraceptive supplies and referrals. Each lady health worker serves approximately 1,000 persons in her own community.
To evaluate the impact of the program on adoption of modern reversible methods, researchers interviewed a random sample of women living in households served by a lady health worker for at least four years as well as a randomly selected comparison group of women living in nonserved communities. Survey participants were asked what method of family planning, if any, they used and whether they had ever used a modern reversible method. Women responding affirmatively to the latter question were also asked when, approximately, they had initially begun use of a modern method. The survey, conducted between October 2000 and April 2001, covered all provinces and federally administered areas of the country. The investigators used weighted, nationally representative data in their analysis, which they restricted to married women living in rural areas.
In general, households in the served communities were better off socioeconomically than those in the control areas, and women had more autonomy. For example, according to data collected from various sources, served communities had a higher proportion of households with a toilet (55% vs. 33%), a higher prevalence of adult female literacy (27% vs. 14%) and a higher proportion of women permitted to visit a health facility outside their village alone (41% vs. 30%). However, the proportion of adult women in the two areas having any radio exposure was the same (34%).
Among respondents aged 23–48 years and married for at least eight years at the time of the survey, the increase in ever-use of modern reversible contraceptives from before the program's implementation to the time of the survey was considerably greater in the group served by the program than in the control group. Among served women, the proportion of ever-users increased from 9% in 1993 to 40% in 2000–2001, compared with 9% to 28% among controls (a difference of 12 percentage points).
A higher proportion of served women than of controls reported current use of any method (30% vs. 21%) and of a modern method (20% vs. 14%); for both measures, the control group averages are similar to previously reported national estimates for 2000–2001 (22% and 15%, respectively). Thirteen percent of the women in the program areas and 7% of controls were currently using a reversible modern method. Two percent and 0.2%, respectively, were pill users; 3% and 1% injectable users; and 4% and 2% IUD users.
The researchers performed logistic regression analyses limited to women with at least one child. After adjustment for numerous characteristics, including socioeconomic variables, women in the program areas were significantly more likely than women in the control group to currently use a modern reversible method (adjusted odds ratio, 1.5). Other characteristics positively associated with women's current use included being educated; having at least two living children; wanting to have no more children; watching television frequently instead of rarely or never; and living in a house with floors made of cement or tiles rather than mud, brick or earth. In contrast, living more than 2 km from the nearest store and residing in Sindh Province instead of Punjab were each associated with decreased odds of use.
The investigators acknowledge that the socioeconomic differences between the program and control areas pose an important study limitation. However, they comment that their analysis nonetheless shows that the Lady Health Worker Program has succeeded in integrating family planning into the doorstep provision of preventive health care and in increasing the use of modern reversible methods in rural areas. The authors also state, In Pakistan, where women's mobility is severely limited and female modesty highly valued, the provision of doorstep services through community-based female workers appears to be one model of service delivery that will help to achieve universal access to family planning by 2010—a primary goal of the government's current population policy.—C. Coren
1. Douthwaite M and Ward P, Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme, Health Policy and Planning, 2005, 20(2):117–123.